Introduction to the new SHC Health Information Record Manual Presented by Rhonda Anderson, RHIA President Anderson Health Information Systems, Inc

SHC in coordination with Anderson Health Information Systems, Inc have developed this manual to provide each center with Health Record specific policies and procedures to facilitate the day to day operations as they relate to Residents’ Health Records

Introduction Each Resident admitted to the center has a record initiated on admission, and completed in accordance with State and Federal Regulations and accepted professional practices. The Health Record is a legal document that describes the health care services provided to the Resident.

Introduction The center is required to have policies and procedures in place, this manual is though comprehensive cannot cover all possible circumstances; therefore, staff must use skill and judgment to determine appropriate actions in a situation not covered herein

Objectives Participants will: Be familiar with the new SHC Health Information Records Manual Learn how to navigate through the manual and locate policies and procedures

Section 0000 Table of Contents Approval / Signatures Alphabetical Index State Specific documentation requirements (California, Iowa, Kansas, Missouri, Nevada, New Mexico & Texas)

Section Organizational chart 1015 Record responsibility: Details the responsibility for establishing and maintaining the Health Record

1016 & 1017 Interview Tools Provides a guideline on interview tools to assist in the medical records director hiring process Provides a baseline for uniform interview questions that will help evaluate all candidates on the same criteria.

1020 Job Description HIM Director Provides an overview of job duties, qualifications, responsibilities and reporting requiremetns for HIM Directors

1035 & 1036 Staff development orientation training Provides a guideline for planning and development of ongoing training to develop and improve the skills of all Center’s personnel.

1037 Orientation / Training Evaluation Checklist A tool to be used to train and evaluate the need for additional training of newly hired personnel, cross training of personnel and development of additional skills of existing personnel. Provides reference to ensure comprehensive training that includes review of related policies and procedures in the Health Information Record Manual Rhonda I am not sure what needs to be documetned in the Eval column, is it the same as the training date or is it the date of the next time it will be evaluated?

Training Priorities Training priorities define timelines for initiation and evaluation of specific areas. Priority 1 items will be covered on days 1-15, Priority 2 items will be covered on days 30-60, Priority 3 items will be covered after 60 days All items will have follow up evaluation during the 1 st quarter following the initial training

1038 Performance Measures Performance measures directly related to section 1039 HIM/ Record Dept system / skills evaluation Used by the coordinators as a uniform guideline of how to review all items contained in section 1039 Provides reference to related federal regulations and related sections of the HIM/ Record Dept system / skills evaluation (1039)

HIM/ Record Dept system / skills evaluation This grid is to be used during Center visits to indicate areas reviewed and provide a performance rating for each area. Recommendations for improvement will be based on performance ratings as evaluated based on the guidelines specified in 1038 and center practices.

1040 HIM Report to Administrator Use this report to summarize trends identified through regular audits during as part of CQI/QA process. This is not a comprehensive report but rather a summation of the key audits in the HIM department. Additional items may need to be reported based on audits and trends identified

Section 2000 The legal record and Definition of record set Provides a description of what is considered the legal medical record, defines the record set and provides a sample record set.

2010 – Documentation Guidelines This section describes general documentation guidelines including process for corrections and late entries Information in this policy can be used to provide orientation to new hires on documentation requirements and ongoing staff training.

2015 – Resident Record Content Provides an overview of all items contained within the Health Record in alphabetical order. The clinical record must contain items and documentation that is timely as required by Federal and State specific regulations

2025 Willful Falsification / Omission Provides guidance as to what constitutes willful falsification and willful omission State specific information on penalties for willful falsification

Section 3000 Readmission policy State specific order of filing for discharge charts Discharge chart monitor Discharge chart monitor instructions and policy and procedure Procedure for closing the record “incomplete”

3005 Readmission Provides guideline for closing the record and initiating a new record upon return of the Resident Provides guidance of new documentation requirements as well as those documents that can be brought forward from the prior record

3520 Discharge Chart Monitor Must be used to review all discharge charts prior to final closure Must be kept with the chart until all items are met and then retained for 1 year in a binder/folder marked “Discharge Monitors” Follow instructions for Incomplete Record Closure when unable to complete deficient items.

3525 Incomplete Record Procedure All records shall be audited and closed within 30 days There may be instances when it is not possible to legally complete the record in which case it must be closed as “incomplete” under direction of the Medical Director This policy provides a list of approved reasons for closing the record as incomplete as well as the procedure to be followed.

Section 4000 This section includes: Department locator HIM record tasks & schedule Filing systems Unit Record Establishing and closing the record Order of filing Thinning Guidelines

Section 4000 Continued…… Chart locator system Lost Record Storage and Destruction of records Off-site Storage Retention of Records

4005 Guide to location of items in the HIM Department Provides a system for identifying location of items contained within the HIM department in the absence of HIM staff.

4010 & 4011 Record Tasks & Schedule 4010 Provides an outline of required tasks and suggestion of how to carry out the tasks throughout the day based on the most efficient order is a sample schedule – to be used to assign monitors based on the performance measures and center specific practice

4020 – Number System Filing Update the policy to specific Center’s number filing system.

4025 – Unit Record Records for Residents with multiple admissions to the Center shall be maintained as a unit to ensure compliance with record retention requirements On discharge all records for the Resident shall be filed together with the latest discharge record

4030 – Establishing and Closing the Record Review this policy for required steps to be followed on admission and discharge of the Resident Update the policy to reflect your Center’s requiremetns and practice

4031 to 4037 – Order of Filing Each policy specifies standard order of filing for organization of in-house resident’s records Each policy includes state specific documentation requirements and retention periods Policy 4040 provides procedure for thinning of records based on these retention guidelines

4040 – Clearance of Records Refer to State specific retention periods specified in policies 4031 to 4037

4050 – Retrieval of Records Chart Locator System The center shall have a system for rapidly locating records at all times. What is your current system? sign out log, out guides? Update the policy to reflect current Center’s practice

4055 – Lost Record This policy provides guidance for reporting the lost record within state specific timelines (update the policy to reflect your state requirements) Provides a procedure for reconstructing the record

4060, 4065, 4070 These policies deal with retention, storage and destruction of records All records shall be retained for a period of 10 years Policy 4070 includes the procedure for destruction of records following the retention period

Section – Master Patient Index Update this policy to reflect current Center’s practice

Section – Delinquent Visit / Follow Up Guidelines for monitoring timeliness of physicians’ visits. Procedure for follow up with the physician and also for dealing with non-compliance by physicians Update the policy with state specific timelines

Section 7050 This section contains the most commonly used monitoring tools and instructions. Quality assurance / improvement monitors shall be utilized in the review of records to provide a clear, concise and detailed review of clinical record content, ensure compliance with regulatory requirements, and timely, complete and accurate documentation.

Section 7050 A schedule will be established for each center as determined by center priorities, The suggested schedule in section 4011should be used to schedule all required monitors. All monitors are arranged in alphabetical order All monitors have accompanying brief instructions detailing the most efficient flow process for completing the audit to include both quantitative and qualitative items

Section 7050 Continued….. Policy 1037 – HIM Director orientation and training refers to the monitors contained in this section with a specified training priority. The trainer shall use the attached instructions as part of the training with hands on practice and return demonstration to assess competency level

Section 7051 This section contains a set of specialized monitors that should be scheduled along with other monitors according to center needs and priorities. These monitors are also arranged in alphabetical order and include completion instructions.

Important The monitors must identify compliant and non-compliant items in order to provide complete information to assess compliance Determine your system for reviewing audit findings, assessing compliance What is your follow up system? How is compliance with audit correction tracked?

Section 9010 Provides a letter that can be utilized to request resident information from the acute hospital to ensure continuity of care upon admission to the Center.

Appendix A Provides links to state specific regulations

Appendix B Provides a tool for requesting clarification or correction of policies and procedures contained in this Health Information / Record Manual

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